Why Obesity Is a Chronic Disease: Answers to Your Questions
by Arya M. Sharma, MD, FRCPC
Q: Regarding the successful weight-loss maintainers you mentioned. Is this something we should be promoting with patients? Could you provide a link to the study?
A: Maintaining weight loss is where the real challenge is in obesity management. The few people (relatively speaking) who do manage to lose a significant amount of weight and keep it off generally eat around 1400 Cal daily, exercise regularly (about 400 Cal worth daily) and weigh themselves frequently. For more information on long-term weight loss maintenance see the findings of the National Weight Weight-Control Registry.
Q: How would a health professional best address "healthy obesity"? At what point would you initiate a health prevention strategy towards individuals with no current health concerns other than an increased body mass? What is the difference in risk for mortality and morbidity between individuals with obesity with healthy behaviors (active, balanced diet) and those with obesity and poor lifestyle behaviors?
A: For people with obesity but no evident health problems (e.g. Edmonton Obesity Staging System Stage 0) it is important to reassure them that they are currently healthy. The focus should be on avoiding further weight gain, maintaining a healthy diet and remaining physically active. Remind them that healthy behaviours are beneficial at any weight.
Q: Do you currently prescribe medications for weight loss? Is this something that you would suggest family/primary care physicians get on board with?
A: I regularly prescribe meds for long-term obesity treatment (not just for weight loss). All health professionals need to realize that using medication for managing obesity is no different than using medication to manage any other chronic disease (e.g. hypertension, diabetes, etc.).
Q: Any idea if/when some of the medications that are currently being used in the US might be available here?
A: Hopefully within the next few years.
Q: What do you think the government/policy makers should do to reduce the current rate of obesity in Canada?
A: This is a complicated question – some potential strategies are outlined in the recent Senate Report on Obesity.
Q: How do we begin to repair the trauma, humiliation and the psychological damage that has and is still affecting us today, despite knowing the new science behind obesity. How do we learn to love ourselves?
A: The Canadian Obesity Network is working hard to address weight bias and discrimination but it will take a considerable amount of effort to change public opinion. At an individual level, a psychologist or social worker trained in counselling can help clients improve their self esteem.
Q: As a dietitian, each week I have patients coming in my office who have made efforts to lose weight by cutting calories under their metabolic needs. What are the expectations for weight loss success in this situation? Is it realistic to first tell them that we need to increase their basal metabolic rate by increasing caloric intake? How long can it take?
A: Unfortunately, the body adapts rapidly to weight loss by reducing its caloric needs. These generally stay low until the weight is regained. This is why most clients will hit a weight-loss plateau and are at high risk of putting the weight back on. Rather than trying to lose and maintain some arbitrary (often unrealistic) amount of weight loss, clients should be counselled to work on finding their “best” weight.
Q: You mentioned the incredible stigma still encountered by people with weight issue in your presentation. Initiatives such as Bell Let's Talk Day and Day of Pink have done a great deal to highlight the stigma against people with mental health issues, online bullying, etc. What sort of initiatives do you think could help reduce the obesity stigma in a similar way?
A: This is something the Canadian Obesity Network is actively working on with its partners through research, as well as looking at other initiatives like the ones you mention.
Q: If someone comes to me as a dietitian and wants help with losing weight and keeping it off, is there anything I can realistically say? Also, I am obese myself, as are some others who work in our field. Some clients might find me easier to work with as I really understand their issues, but others think I'm a horrible example and would never listen to anything I have to say.
A: Your focus should be to help clients understand that developing health behaviours is more important than trying to achieve some arbitrary (often unrealistic) weight loss. Clients need to understand that obesity is a chronic (often life-long) disease and that management approaches have to be sustainable. Many health care providers struggle with their weight (incidentally proving that knowledge is not enough to prevent or manage obesity). Clients who would rather have a lean health care practitioner may not understand what it is they are really up against.
Q: We were curious about the type of medications that are currently available to patients with obesity.
A: The prescription medications currently approved for obesity treatment in Canada are the gastrointestinal lipase-inhibitor orlistat (Xenical®) and the GLP-1 analogue liraglutide (Saxenda®).
Q: Re: the connection between overweight, stigma and resulting mental health problems (i.e., shame). What happens to the body if we manage to lower the level of shame?
A: There are studies which suggest that improving self-esteem can reduce health risks.
Q: How does one motivate a person with obesity to continue fighting against their own physiology to not give up when they learn that their body will constantly be fighting to get back to a set point? This fact is quite eye-opening and, well, disheartening.
A: Understanding that obesity is a chronic disease just means that it has to be managed over the long term. This is no different than living with any other chronic disease like such as diabetes or depression.
Q: What are ways that a person with obesity can adapt to the "battle" with their body in "controlling" their weight?
A: To focus on being the healthiest you can at any weight and by being realistic in what health behaviours are sustainable in the long term. “Quick-fix” approaches never work and there are no magic pills that your “doctor does not want you to know about.”
Q: Dr. Sharma I wish you could broadcast a TV show about this or put it on YouTube. And thank you so much for doing this webinar!
A: Thanks! The webinar is available online here.
Q: I am a family doctor and obesity board certified physician working in the USA. Of course you are aware of the current FDA-approved medications here; my question is why are they not available in Canada?
A: This is largely a question of commercial interest – it is up to the companies who make these medications to approach Health Canada for approval.
Q: Is there any advocacy going on to support use of GLP1 medications for weight loss?
A: Novo Nordisk, the maker of the GLP-1 analogue liraglutide (Saxenda®) is working with payers to increase coverage for this anti-obesity medication. You can support this work by talking to your employer and to your benefits provider to request coverage for obesity treatments.
Q: I wonder why physicians are not required to become better educated on obesity. Their ignorance contributes to the problem (ie: shaming fat people can cause low self esteem, emotional issues and using food as comfort).
A: The Canadian Obesity Network has developed a number of educational programs for training health professionals (including physicians) in obesity management (e.g. the 5As of Obesity Management). There are also an increasing number of Canadian physicians who have taken the American Board of Obesity Medicine exam.
Q: If the body is so effective in 'protecting' the obese state (and preventing weight loss), why is it so easy for individuals to reach an obese state in the first place? Why is the body not more effective in protecting a healthy body weight?
A: Unfortunately, the body is far less effective in protecting against weight gain than against weight loss. However, it is easier to lose weight that you have recently gained than weight that you have gained gradually over the years.
Q: Is calling obesity a disease going to reduce discrimination against obese people?
A: Simply calling obesity a disease does not reduce discrimination but it is one step in the process. The Canadian Obesity Network is working hard to change how we think and talk about obesity. You can do your part by supporting our work.
Q: Is group counselling on weight maintenance or individual counselling more effective?
A: Many people find group support helpful in long-term weight maintenance. However, not everyone likes groups or finds them helpful. As with everything in obesity management, approaches need to be individualized to what works best for a given client.
Q: Should we be telling clients that 3-5% weight loss maintenance for the long term is success, even if they have initial weight loss was significantly more? Does this give them realistic ideas/goals or would this make them want to give up?
A: There is plenty of evidence that even a 3-5% weight loss (if maintained) can have substantial health benefits. Rather than picking an arbitrary number, clients should be advised to aim for their “best” weight.
Q: Should I be telling my clients that they have a disease and they will require ongoing treatment from me or the MD?
A: Irrespective of whether you call it a disease or not, your client will have to understand that they will need long-term (life-long?) support, no different than if they had hypertension or diabetes.
Q: What do we do if our family doc won't help?
A: The Canadian Obesity Network is working hard to educate physicians and other health professionals on obesity management. Perhaps you can point him/her to the network's professional resources.
Q: How do we access local programs?
A: You can start by checking out the website of your health authority or health region. You should also talk to your physician or other health professionals about what programs are available in your region.